MEDICARE: MISS EUNJIN M SUH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D30956	TX

General Provider Information

NPI Number	:	1003284969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS EUNJIN M SUH DDS

Provider Business Mailing Address
First Line	:	500 N TARRANT PKWY APT 122
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-5677
Country	:	US
Telephone Number	:	512-788-3705
Fax Number	:

Provider Business Practice Location Address
First Line	:	5416 BASSWOOD BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-4400
Country	:	US
Telephone Number	:	817-656-1215
Fax Number	:	877-230-8349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	09/09/2015

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